Introduction

February 8, 2011

Two prominent Republican senators are pushing Medicare’s administrator to block convicted felons and doctors with revoked licenses from successfully billing the federal health care program for the elderly, an issue that was highlighted by iWatch News early this year.

In the letter to Donald Berwick, administrator of the Centers for Medicare and Medicaid Services (CMS), Sen. Orrin Hatch, R-Utah, and Sen. Tom Coburn, R-Oklahoma, wrote that Medicare contractors are allowing doctors and scam artists to retain Medicare billing privileges even if they have lost their medical licenses or have been convicted of felonies related to tax evasion, health care fraud, and “lewd and lascivious conduct.” Medicare contracts with 11 companies nationwide to administer claims for the program. The letter also includes a list of possibly dubious practitioners and a request that CMS determine if they should be revoked from the program.

“By not taking the appropriate administrative action against providers and suppliers who are convicted or who have pled guilty to financial crimes and other felonies … CMS is abdicating its financial responsibility and placing Medicare beneficiaries at increased risk of poor quality health care,” the senators wrote.

The Medicare program has long been a lucrative target for criminals; Attorney General Eric Holder estimated the program loses $60 billion a year to fraud. Early this year, iWatch News reported that criminals successfully billed Medicare for prescription drugs using the names of deceased physicians, a scam that is difficult to catch due to inadequate CMS oversight of contractors. At that time, CMS was not checking to make sure that prescriptions paid for by the program were written by real doctors. Oversight of contractors was so inadequate that the agency could not identify the top prescribers of oxycodone and Ritalin, two highly addictive drugs that are often trafficked on the streets.

According to this week’s letter by Hatch and Coburn, CMS and its contractors may also have failed to determine the criminal status of Medicare providers or check whether they have valid medical licenses. The Senators faulted “the apparent lack of meaningful coordination and communication” between CMS, the Department of Justice, and the Internal Revenue Service. They also expressed concern that Medicare contractors “may be failing to investigate and … revoke” Medicare billing privileges of physicians whose medical licenses have been suspended or revoked.

The senators requested that Berwick explain how the agency communicates with federal law enforcement agencies to ensure it learns of felony convictions, and describe the process through which the agency removes doctors from the program when they are convicted or plead guilty to health care fraud. The senators also asked the agency to explain how it verifies that its contractors are on the lookout for doctors whose licenses are revoked.

Ellen Griffith, a CMS spokeswoman, declined to comment because the agency has not yet had a chance to review the letter.